Annals of Family Medicine

NOVEMBER 20, 2024

Intervention/Instrument: The screening tool used in the pilot sites included five questions to assess needs related to transportation, food insecurity, utility payments, housing, and a final question to assess patients’ willingness to receive help.

Referral 130

Referral Community Transportation Utilities 130

Annals of Family Medicine

NOVEMBER 20, 2024

Population Studied: We conducted focus groups, key informant interviews, and in-depth interviews with leaders from ODM, CBOs, and regional health systems, triangulated with thematic review of community health needs assessments.

Community 130

Community Diabetes Referral Screening 130

Annals of Family Medicine

NOVEMBER 20, 2024

Setting or Dataset: Secondary data on social needs screening and referral generated through Epic. Intervention/Instrument: The intervention includes a short survey to determine patients’ needs with respect to transportation, food insecurity, financial difficulty related to utility payments, and housing.

Primary Care 130

Primary Care Referral Routine Screenings Patients 130

Annals of Family Medicine

NOVEMBER 20, 2024

A recent review of national diabetes treatment guidelines recommended adjustments to DM to reduce financial strain (eg, selecting lower cost medications), as well as directly intervening in response to an identified social need (eg, referral to a community-based service).

Primary Care 130

Primary Care Diabetes Management Provider 130

Annals of Family Medicine

NOVEMBER 20, 2024

Intervention: LINK is a randomized controlled 2x2 factorial trial testing the effect of 2 distinct interventions on A1c: a 6-week culinary and nutrition education class and community referrals to address unmet social needs. Transportation and scheduling challenges also hindered engagement.

Diabetes 130

Diabetes Clinic Transportation Internal Medicine 130

PEMBlog

MAY 20, 2025

And I always say that I do not envy my emergency medicine colleagues, particularly those practicing in community settings. And so we routinely do outreach with our community providers. Another recommendation that I have is regarding transport calls. They’re not just the test referral center.

Family 101

Family Families Hospital Patient-Centered 101

GeriPal

FEBRUARY 15, 2024

So Carmen and Katie developed an EMS Community Partnership program. They created a seamless link between this Community Partnership program and 911 calls for falls. Eric and I enjoyed talking with Carmen and Katie about this innovative and common sense approach to addressing falls in the community. What can we do as a community?

Community 115

Community Transportation IT PCP 115